An 11-year-old boy has bullied younger children, initiated physical fights, been cruel to the family dog, deliberately set fire to a neighbor's shed, and repeatedly stolen goods while confronting the victims. These behaviors began before age 10 and have caused significant impairment. His parents describe little guilt or remorse. Which is the most likely diagnosis?

• A Oppositional defiant disorder
• B Adjustment disorder with disturbance of conduct
• C Intermittent explosive disorder
• D Conduct disorder, childhood-onset type ✓

Explanation

Conduct disorder is diagnosed when there is a repetitive pattern violating rights of others through aggression to people and animals, destruction of property, deceitfulness or theft, and serious rule violation. Cruelty to animals, fire setting, and robbery with confrontation of the victim place him firmly beyond defiance. Oppositional defiant disorder is limited to angry, argumentative, vindictive behavior without aggression toward people or animals or property destruction, which is the fact that kills that distractor. Onset before age 10 defines the childhood-onset subtype.

Reference: Nelson Textbook of Pediatrics, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.